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User Guide

2014 Electronic Prescribing (eRx) Payment Adjustment Feedback Report


Disclaimer This information was current at the time it was published or uploaded onto the web. Medicare policy changes frequently so links to the source documents have been provided within the document for your reference. This document was prepared as a tool to assist eligible professionals and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services. The Centers for Medicare & Medicaid Services (CMS) employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide. This publication is a general summary that explains certain aspects of the Medicare Program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings. Current Procedural Terminology (CPT®) only copyright 2012 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.


Table of Contents Purpose ............................................................................................................................................................ 4

2014 eRx Payment Adjustment Overview ...................................................................................................... 4

Inclusion Criteria .................................................................................................................................. 5 Individual Eligible Professionals .................................................................................................................... 5 eRx GPRO .................................................................................................................................................... 5

Avoiding the 2014 eRx Payment Adjustment ..................................................................................... 5 Individual Eligible Professionals .................................................................................................................... 5 eRx GPRO .................................................................................................................................................... 5

2014 eRx Payment Adjustment Feedback Report Overview ........................................................................ 6

System Requirements for the Portal .............................................................................................................. 6

Hardware .............................................................................................................................................. 7

Software ................................................................................................................................................ 7

Internet Connection ............................................................................................................................. 7

eRx Payment Adjustment Feedback Report Content and Appearance ....................................................... 7

Table 1: Reporting Summary for the Tax ID or TIN ............................................................................ 7 Example 1.1: Reporting Summary for the Tax ID or TIN (Non-eRx GPRO) ................................................. 8 Example 1.2: Reporting Summary Tax ID or TIN (eRx GPRO) .................................................................... 9

Table 2: NPI Reporting Detail (Available to Non-eRx GPRO Individuals) ....................................... 10 Example 2.1: NPI Reporting Detail (Non-eRx GPRO) ................................................................................ 11

Accessing Feedback Reports ....................................................................................................................... 12

NPI-Level Reports (Available to Non-eRx GPRO Individuals) ......................................................... 12

TIN-Level Reports (Available to eRx GPROs and Other Group Practices) .................................... 12

Key Facts about the 2014 eRx Payment Adjustment .................................................................................. 14

2014 eRx Payment Adjustment Calculations ................................................................................... 14

2014 eRx Payment Adjustment Application ..................................................................................... 14

Frequent Concerns ............................................................................................................................ 15

Help/Troubleshooting .................................................................................................................................... 15

Copyright, Trademark, and Code-Set Maintenance Information ................................................................ 15

Appendix A: 2014 eRx Payment Adjustment Feedback Report Definitions .............................................. 16

Table 1: Reporting Detail for the Taxpayer Identification Number (Tax ID or TIN) ........................ 16

Table 2: NPI Reporting Detail (Individuals Only) ............................................................................. 18


User Guide 2014 Electronic Prescribing (eRx) Payment Adjustment

Feedback Report Purpose The 2014 Electronic Prescribing (eRx) Payment Adjustment Feedback Report User Guide is designed to assist eligible professionals, group practices participating in eRx Group Practice Reporting Option (GPRO), and their authorized users in accessing and interpreting the 2014 eRx Payment Adjustment Feedback Report. The 2014 eRx Payment Adjustment Feedback Report reflects partial reporting year data from Medicare Part B Physician Fee Schedule (PFS) claims with dates of service of January 1–October 31, 2012 that were processed into the National Claims History (NCH) by December 31, 2012 (the last Friday in December is the 28th and data will not be processed throughout the weekend). The 2014 eRx Payment Adjustment Feedback Report is an interim report based on partial-year reporting that allows providers to determine their status in meeting the 2012 eRx Incentive Program requirements for being a successful electronic prescriber. Eligible professionals and CMS-selected group practices participating in eRx GPRO who are deemed successful electronic prescribers for the 2012 eRx Incentive Program will be automatically exempt from the 2014 eRx payment adjustment for that Taxpayer Identification Number (Tax ID Number, or TIN). Eligible professionals and group practices participating in eRx GPRO deemed unsuccessful at meeting the 2012 eRx Incentive Program requirements based on the 2014 eRx Payment Adjustment Feedback Report are able to work towards avoiding the 2014 eRx payment adjustment by meeting the 2013 eRx 6-month (January 1–June 30, 2013) reporting requirements. Additional information is available on the CMS website at http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ERxIncentive/. Note: This report does not provide final determination on whether or not the eligible professional or eRx GPRO has met the satisfactory reporting criteria for the 2012 eRx Incentive Program, or is eligible for incentive payment. Additionally, 2012 eRx program data submitted via registry reporting, or qualified EHR systems will not be included in this report; rather, that information will be available for review in the fall of 2013 through the final 2012 eRx Incentive Program Feedback Report. 2014 eRx Payment Adjustment Overview Section 1848(m) of the Social Security Act authorizes the Centers for Medicare & Medicaid Services (CMS) to subject eligible professionals who are not successful electronic prescribers under the eRx Incentive Program to future payment adjustments. All eligible professionals had the opportunity to avoid the 2014 eRx payment adjustment by meeting the criteria for becoming a successful electronic prescriber in 2012 during the 12-month reporting period (January 1–December 31, 2012), and again in 2013 during the 6-month reporting period (January 1–June 30, 2013). To avoid the 2014 eRx payment adjustment, an eligible professional had to electronically prescribe via a CMS-qualified eRx system, and report the required number of valid eRx Incentive Program quality-data codes (QDCs) for Medicare Part B PFS services, as defined by the eRx Incentive Program measure specifications available on the CMS website at http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ERxIncentive/. The eRx Incentive Program QDC (G8553) indicates that at least one electronic prescription was created during an eRx Incentive Program measure-eligible visit (also known as an eRx denominator-eligible event as defined in the eRx Incentive Program measure specification), and was transmitted electronically using a CMS-qualified eRx system. For the 12-month eRx reporting period (January 1–December 31, 2012), valid QDC submissions were counted when the eRx QDC (G8553) was submitted via claims, qualified registry, or qualified EHR system, and all measure-eligibility criteria was met if applicable (i.e., correct Current Procedural Terminology, or CPT code). For the 6-month eRx reporting period (January 1– June 30, 2013), valid eRx Incentive Program QDC submissions were counted when the eRx QDC (G8553) was submitted via claims for any Medicare Part B PFS service.

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ERxIncentive/index.html?redirect=/ERXincentive/




Eligible professionals could have submitted the eRx Incentive Program QDC as an individual eligible professional, or as a CMS-selected group practice participating in the eRx GPRO. Only group practices who self-nominated, indicated the intent of reporting eRx as a 2012 eRx GPRO during the self-nomination period, and participated in the 2012 Physician Quality Reporting System (PQRS) GPRO were eligible to submit the eRx QDC during the reporting period as an eRx GPRO. Inclusion Criteria Individual Eligible Professionals The 2014 eRx payment adjustment will only apply to those individual eligible professionals who met all of the following criteria:

• Met the aforementioned taxonomy criteria (doctor of medicine, doctor of osteopathy, doctor of podiatric medicine, nurse practitioner, or physician assistant) based on NPPES primary specialty taxonomy criterion for the 2013 eRx 6-month reporting period;

• Have more than 10% of allowed charges for the 2013 eRx 6-month reporting period (January 1–June 30, 2013) comprised of codes in the denominator of the 2013 eRx measure; AND

• Have more than 100 cases containing an encounter code in the measure’s denominator during the 2013 eRx 6-month reporting period.

eRx GPRO The 2014 eRx payment adjustment will only apply to those group practices participating in 2013 eRx GPRO who met all of the following criteria:

• Have more than 10% of the eRx GPRO’s allowed charges for the 2013 eRx 6-month reporting period (January 1–June 30, 2013) comprised of codes in the denominator of the 2013 eRx measure.

Avoiding the 2014 eRx Payment Adjustment Individual Eligible Professionals Individual eligible professionals who meet the above inclusion criteria may receive 98.0% of the PFS amount (or 2.0% less) for covered professional services rendered from January 1–December 31, 2014 if they did not:

• Become successful electronic prescriber during the 2012 eRx 12-month reporting period (January 1–December 31, 2012); or

• Become a successful electronic prescriber during the 2013 eRx 6-month reporting period (January 1–June 30, 2013); or

• Request a 2013 eRx significant hardship exemption, or submit a lack of prescribing privileges G-code Individual eligible professionals were required to submit at least 25 unique denominator-eligible eRx events during the 2012 eRx 12-month reporting period to be automatically exempt from the 2014 eRx payment adjustment. Analysis of all 2012 eRx data will be completed in the fall of 2013 for a final determination of whether or not eligible professionals will be automatically exempt from the 2014 eRx payment adjustment, or eligible for an incentive payment. Individual eligible professionals have a second chance to avoid the 2014 eRx payment adjustment by requesting a significant hardship exemption, or indicate lack of prescribing privileges reporting, or report at least 10 eRx events on any billable Medicare Part B PFS claim with a date of service during the 2013 eRx 6-month reporting period (January 1–June 30, 2013). Individual eligible professionals need to meet the reporting criteria for each TIN under which (s)he worked during 2012 and/or 2013 to avoid the 2014 eRx payment adjustment for each TIN. Analysis of the 2012 and 2013 eRx reporting periods to determine subjectivity of the 2014 eRx payment adjustment is at the TIN/National Provider Identifier (NPI) level. eRx GPRO Group practices participating in eRx GPRO who met the above inclusion criteria may receive the 2014 eRx payment adjustment of 98.0% of the PFS amount (or 2.0% less) for covered professional services rendered from January 1–December 31, 2014 if they:

• Failed to become successful electronic prescribers during the 2012 eRx 12-month reporting period (via reporting method provided during self nomination); or

• Failed to become a successful electronic prescriber during the 2013 eRx 6-month reporting period (via claims); or • Failed to request a 2014 eRx significant hardship exemption.

Large CMS-selected group practices participating in 2012 eRx GPRO (100 or more eligible professionals) were required to submit at least 2,500 unique denominator-eligible eRx events via the reporting method indicated during the self


nomination period for the 2012 eRx 12-month reporting period to be automatically exempt from the 2014 eRx payment adjustment. Small CMS-selected group practices participating in 2012 eRx GPRO (25-99 eligible professionals) were required to submit at least 625 unique denominator-eligible eRx events via the reporting method indicated during the self nomination period for the 2012 eRx 12-month reporting period to be automatically exempt from the 2014 eRx payment adjustment. Exemption from the 2014 eRx payment adjustment based on 2012 eRx GPRO reporting assumes that the eRx GPRO status of each group remains the same through consecutive program years. ERx GPROs have a second chance to avoid the 2014 eRx payment adjustment by requesting a significant hardship exemption or by meeting the reporting criteria as set forth in the final 2013 PFS rule to avoid the 2014 eRx payment adjustment. Analysis of the 2012 and 2013 eRx reporting periods to determine subjectivity of the 2014 eRx payment adjustment is at the TIN level for group practices participating in eRx GPRO. Additional information on 2013 eRx Incentive Program reporting requirements is available on the CMS website at http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ERxIncentive/. 2014 eRx Payment Adjustment Feedback Report Overview The 2014 eRx Payment Adjustment Feedback Report provides interim analysis of partial-year data from Medicare Part B PFS claims received for services rendered January 1–October 31, 2012 that were processed into the NCH by December 31, 2012 (the last Friday in December is the 28th and data will not be processed throughout the weekend). The 2014 eRx Payment Adjustment Feedback Report provides a status check on where the eligible professional or CMS-selected eRx GPRO is in meeting the 2012 eRx Incentive Program requirements for being a successful electronic prescriber, and; therefore, automatically exempt from the 2014 eRx payment adjustment. Eligible professionals deemed unsuccessful at meeting the 2012 eRx Incentive Program requirements have a second chance to avoid the 2014 eRx payment adjustment by meeting the 2013 eRx 6-month reporting requirements (January 1–June 30, 2013). The 2014 eRx Payment Adjustment Feedback Report will be accessible to individual eligible professionals who met the aforementioned taxonomy criteria and CMS-selected group practices participating in eRx GPRO who submitted at least one Medicare Part B PFS claim containing an eRx denominator-eligible service rendered January 1–October 31, 2012 that was processed into the NCH by December 31, 2012 (the last Friday in December is the 28th and data will not be processed throughout the weekend). The 2014 eRx Payment Adjustment Feedback Report will not reflect the following:

• Data analysis of the full 2012 eRx 12-month reporting period and claims run-out processing period (claims with dates of service January 1–December 31, 2012, with a processing period through February 22, 2013)

• 2012 QDCs submitted via registry reporting, or qualified EHR systems • Whether or not the individual eligible professional or eRx GPRO meets the 2013 eRx 6-month (January 1–June

30, 2013) reporting requirements or eligibility criteria • 2014 eRx payment adjustment hardship exemptions (including hardship G-codes submitted via claims or

requested through the Communication Support Page, or EHR Incentive Program participation) • 2012 eRx Incentive Program Informal Review and/or 2014 eRx Payment Adjustment Informal Review final

decision 2014 eRx Payment Adjustment Feedback Report provides individual/rendering NPI- and TIN-level data. Individual eligible professionals who met the aforementioned taxonomy eligibility criteria, and submitted Medicare Part B PFS claims containing an eRx denominator-eligible visit will be able to request NPI-level reports, in addition to viewing their NPI data within the TIN-level report. TIN-level reports summarize the reporting of many individual NPIs within one practice, and also include NPI level data. CMS-selected group practices participating in eRx GPRO will only have TIN-level reports available. 2014 eRx Payment Adjustment Feedback Report will be made available in spring 2013. For more information on future eRx payment adjustments, see the CMS website at http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ERxIncentive/. System Requirements for the Portal Minimum hardware and software requirements to effectively access and view the feedback reports on the Physician and Other Health Care Professionals Quality Reporting Portal (Portal) are listed below.






Hardware • 233 MHz Pentium processor with a minimum of 150 MB free disk space • 64 MB RAM (128 MB is recommended)

Software • Microsoft® Internet Explorer version 8.0 • Adobe® Acrobat® Reader version 5.0 and above, or Microsoft® 2007 Excel • JRE is 1.6.0_21, software is available for download on the Portal • Windows® XP operating system Internet Connection The Portal will be accessible via any Internet connection running on a minimum of 33.6k or high-speed Internet.

eRx Payment Adjustment Feedback Report Content and Appearance 2014 eRx Payment Adjustment Feedback Reports will be available for all individual eligible professionals who met the aforementioned taxonomy eligibility criteria and group practices participating in eRx GPRO who submitted at least one denominator-eligible Medicare Part B PFS claim with a date of service during the 2012 eRx partial-year reporting period (January 1–October 31, 2012). Individuals and group practices participating in eRx GPRO will be able to access a TIN-level report. The TIN-level feedback report is only accessible by the TIN.

Table 1: Reporting Summary for the Tax ID or TIN Individual eligible professional’s TIN-level report will receive the following information for each NPI in Table 1 of the feedback report (see Example 1.1): • Reporting Denominator: Applicable Cases that Could be Reported: The number of events for which the

TIN/NPI was eligible to report the measure. • Reporting Numerator: Valid Unique eRx G-Codes Reported: The number of reporting events where the

eRx QDCs submitted met the measure specific reporting criteria. At least 25 valid non-hardship eRx G-codes reported during the 12-month reporting period are required to avoid the payment adjustment.

• Currently Subject to the 2014 eRx Payment Adjustment: Indicates whether an eligible professional may be subject to the 2014 eRx payment adjustment based on preliminary analysis. The eligible professional may still be able to avoid the 2014 payment adjustment if the eligible professional became a successful electronic prescriber in 2012, by submitting additional QDCs after the October 31, 2012 preliminary analysis, or by meeting the 2013 eRx 6-month reporting criteria.

Group practices participating in eRx GPRO will receive the following information in Table 1 of the feedback report (see Example 1.2): • Reporting Denominator: Applicable Cases that Could be Reported: the number of events for which the

GPRO was eligible to report the measure. • Reporting Numerator: Valid Unique eRx G-codes Reported: the number of reporting events where the

eRx QDCs submitted met the measure-specific reporting criteria for group practices participating in eRx GPRO. A successful eRx GPRO was required to report the following number of eRx QDCs during the 2012 reporting period:

25-99 NPIs = 625 eligible unique visits 100 or more NPIs = 2,500 eligible unique visits

• Currently Subject to the 2014 eRx Payment Adjustment: Indicates whether group practice participating in eRx GPRO may be subject to the 2014 eRx payment adjustment based on preliminary analysis. The group practice participating in eRx GPRO may still be able to avoid the 2014 payment adjustment if the eRx GPRO became a successful electronic prescriber in 2012, by submitting additional QDCs after the October 31, 2012 preliminary analysis, or by meeting the 2013 eRx 6-month reporting criteria.

For definition of terms related to 2014 eRx payment adjustment feedback reports see Appendix A. Also refer to the footnotes within each table for additional content detail.


Example 1.1: Reporting Summary for the Tax ID or TIN (Non-eRx GPRO)

Figure 1.1 Screenshot of Table 1: Reporting Summary for the Taxpayer Identification Number (Tax ID) - Individual


Example 1.2: Reporting Summary Tax ID or TIN (eRx GPRO)

Figure 1.2 Screenshot of Table 1: Reporting Summary for the Tax ID or TIN (eRx GPRO)


Table 2: NPI Reporting Detail (Available to Non-eRx GPRO Individuals) Individual eligible professionals who met the taxonomy eligibility criteria, and submitted at least one denominator-eligible Medicare Part B PFS claim with a date of service during the 2012 eRx preliminary reporting period (January 1–October 31, 2012) will be able to access an NPI-level report (Table 2). An individual eligible professional will receive the following information in Table 2 of the feedback report (see Example 2.1):

• Reporting Denominator: Applicable Cases that Could be Reported: the number of events for which the

TIN/NPI was eligible to report the measure. • Reporting Numerator: Valid Unique eRx G-Codes Reported: The number of reporting events where the

eRx QDCs submitted met the measure specific reporting criteria. At least 25 valid non-hardship eRx G-codes reported during the reporting period are required during the 12-month reporting period to avoid the payment adjustment.

• Currently Subject to the 2014 eRx Payment Adjustment: Indicates whether an eligible professional may be subject to the 2014 eRx Payment Adjustment based on preliminary analysis. The eligible professional may still be able to avoid the 2014 eRx payment adjustment if the eligible professional became a successful electronic prescriber in 2012, by submitting additional QDCs after the October 31, 2012 preliminary analysis, or by meeting the 2013 eRx 6-month reporting criteria.


Example 2.1: NPI Reporting Detail (Non-eRx GPRO)

Figure 2.1 Screenshot of Table 2: NPI Reporting Detail (Available to Non-eRx GPRO Individuals)


Accessing Feedback Reports NPI-Level Reports (Available to Non-eRx GPRO Individuals) Eligible professionals who submitted claims as an individual NPI (including sole proprietors who submitted claims under a SSN) can request their individual NPI-level feedback reports through the Communication Support Page available at http://www.qualitynet.org/pqrs under the “Related Links” section in the upper left-hand corner of the window. Please allow 2-3 days for processing. Individuals can access the TIN-level report (which includes NPI-level data for all individual eligible professionals under that TIN) through the Portal with IACS login as discussed in the next section. Note: As of March 16, 2012, eligible professionals are no longer able to contact their Carrier or A/B MAC for NPI-level feedback reports. TIN-Level Reports (Available to eRx GPROs and Other Group Practices) TIN-level reports can be requested for individuals within the same practice or for CMS-selected group practices participating in eRx GPRO who submitted at least one denominator-eligible claim during the 2012 eRx preliminary reporting period (January 1–October 31, 2012). These TIN-level reports are accessible through the Portal, http://www.qualitynet.org/pqrs, with an IACS login. TIN-level reports can only be accessed via the Portal. The Portal is the secured entry point to access the 2014 eRx payment adjustment feedback reports. The report is safely stored online and accessible only to the eligible professional (and those specifically authorized). Eligible professionals will need to obtain an IACS account for an “end user” role in order to access their 2014 eRx payment adjustment feedback reports through the Portal. As shown in Figure 3.1, the Quick Reference Guides provide step-by-step instructions to request an IACS account to access the Portal, if you do not already have one. Downloadable 2014 eRx payment adjustment TIN-level feedback reports will be available as an Adobe® Acrobat® PDF in the spring of 2013 via the Portal. The report will also be available as a Microsoft® Excel or .csv file. CMS established the QualityNet Help Desk to support access to and registration for IACS. The QualityNet Help Desk can be reached at 1-866-288-8912 (TTY 1-877-715-6222) or by e-mail at [email protected]. Hours of operation are Monday through Friday 7:00 a.m. to 7:00 p.m. CST. Note: This 2014 eRx Payment Adjustment feedback report may contain a partial or "masked" Social Security Number/Social Security Account Number (SSN/SSAN) as part of the TIN field. Care should be taken in the handling and disposition of this report to protect the privacy of the individual practitioner with which the SSN is potentially associated. Please ensure that these reports are handled appropriately and disposed of properly to avoid a potential Personally Identifiable Information (PII) exposure or Identity Theft risk. The PQRS Portal User Guide (http://www.qualitynet.org/pqrs) provides detailed instructions for logging into the Portal.

http://www.qualitynet.org/pqrs


mailto:[email protected]



Figure 3.1 Screenshot of Physician and Other Health Care Professionals Quality Reporting Portal


Key Facts about the 2014 eRx Payment Adjustment 2014 eRx Payment Adjustment Calculations

• Subjectivity to receive the eRx payment adjustment is based on CMS final analysis of the following data submissions:

o All valid 2012 eRx denominator-eligible QDCs submitted via claims, qualified registry, or a qualified EHR system with a date of service during the 12-month reporting period (January 1–December 31, 2012), OR

o If not a successful electronic prescriber in 2012, all valid 2013 eRx QDCs submitted via claims with a date of service during the 6-month reporting period (January 1–June 30, 2013), that are processed into NCH by July 26, 2013

• Individual eligible professionals will be analyzed at the individual TIN/NPI level to determine reporting success. An individual eligible professional who would be subject to the 2014 eRx payment adjustment includes one who:

o Failed to meet the 2013 eRx 6-month reporting criteria o Did not request a hardship exemption, or lack of prescribing privileges during the 2013 eRx 6-month

reporting period o Failed to meet the 2012 eRx 12-month criteria for successful reporting

• eRx GPROs will be analyzed at the TIN level to determine reporting success. All NPIs under the TIN may be subject to the payment adjustment if the eRx GPRO fails as a group. A group practice participating in eRx GPRO that would be subject to the 2014 eRx payment adjustment includes one who:

o Failed to meet the 2013 reporting criteria during the 2013 eRx 6-month reporting period o Did not request a hardship exemption, or lack of prescribing privileges during the eRx 6-month reporting

period o Failed to meet the 2012 eRx 12-month criteria for successful reporting

• For eligible professionals who submitted claims under multiple TINs, CMS groups claims by TIN/NPI for analysis and payment adjustment purposes. As a result, a professional who submitted claims under multiple TINs in 2012 may be subject to an eRx payment adjustment under one of the TINs and not the other(s), or may be subject to a payment adjustment under each TIN.

• For individuals, the eRx payment adjustment analysis and application is based on the TIN/individual rendering NPI combination during the reporting period. If an individual eligible professional (individual NPI) completed his or her 2012 reporting under an old TIN, and then bills under a new TIN starting January 1, 2013, his/her 2012 reporting will not carry over to the new TIN. If the 2014 eRx Payment Adjustment Feedback Report indicates that an individual eligible professional met the 2012 eRx 12-month reporting criteria under his/her old TIN, (s)he will not be automatically exempt from the 2014 eRx payment adjustment under a new TIN. Therefore, (s)he must become a successful electronic prescriber during the 2013 eRx 6-month reporting period under the new TIN in order to avoid the 2014 eRx payment adjustment.

• For group practices participating in eRx GPRO, the eRx payment adjustment analysis and application is based on the reporting TIN. If a group practice participating in eRx GPRO changes TINs during the reporting period, CMS will group claims by TIN for analysis and payment adjustment purposes. As a result, only data submitted under the old TIN (used when self-nominating) will be analyzed as an eRx GPRO, and data submitted under the new TIN will be analyzed as individual NPIs for that reporting period. If the eRx GPRO successfully reported in 2012, those NPIs under the eRx GPRO will not be automatically exempt from the 2014 eRx payment adjustment under the new TIN. Therefore, the 2013 eRx GPRO must become successful electronic prescribers under the new TIN during the 2013 eRx 6-month reporting period in order to avoid the 2014 eRx payment adjustment.

2014 eRx Payment Adjustment Application

• The eRx payment adjustment for not being a successful electronic prescriber will result in an individual eligible professional, or group practice participating in an eRx GPRO, receiving 98.0% of his or her Medicare Part B PFS amount that would otherwise apply to such services (or 2.0% less TIN reimbursement) for all charges with a date of service from January 1–December 31, 2014.

• The TIN/NPI will receive adjusted Medicare Part B reimbursements as (s)he would normally receive payment for Medicare Part B PFS covered professional services furnished to Medicare beneficiaries.

• The eRx payment adjustments will be applied separately from the eRx Incentive Program or any other CMS incentive program incentive payments.

• If a TIN/NPI submits claims to multiple Medicare claims processing contractors (Carriers or A/B MACs) and is subject to the eRx payment adjustment, each contractor will payout 2.0% less for all the Medicare Part B PFS claims the contractor processes with a date of service from January 1–December 31, 2014.

• For further information related to eRx payment adjustments, please refer to the Payment Adjustment Information section on the CMS eRx Incentive Program website at http://www.cms.gov/Medicare/Quality-Initiatives-Patient-



Assessment-Instruments/ERxIncentive/ and MLN document SE1206 at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1206.pdf.

Frequent Concerns

• If the TIN/NPI is not subject to the eRx payment adjustment and does see a payment adjustment, contact the QualityNet Help Desk, 1-866-288-8912 (TTY 1-877-715-6222) or by e-mail at [email protected].

• Eligible professionals will not receive claim-level detail in the eRx payment adjustment feedback reports. • 2014 eRx payment adjustment feedback report availability is not based on whether or not the eligible professional

will be subject to a future payment adjustment. • Hardship exemptions or requests will not be reflected in the 2014 eRx Payment Adjustment Feedback Reports.

Help/Troubleshooting Following are helpful hints and troubleshooting information:

• Adobe® Acrobat® Reader is required to view the feedback report in PDF format. You can download a free copy of the latest version of Adobe® Acrobat® Reader from http://www.adobe.com/products/acrobat/readstep2.html?promoid=BUIGO.

• The report may not function optimally, correctly, or at all with some older versions of Microsoft® Windows, Microsoft® Internet Explorer, Mozilla® Firefox, or Adobe® Acrobat® Reader.

• Feedback reports are generated in the 2007 version of Microsoft® Excel. Microsoft offers a free viewer application for opening Office 2007 files to users running Windows Server 2003, Windows XP, or Windows Vista Operating Systems. With Excel Viewer, you can open, view, and print Excel workbooks, even if you do not have Excel installed. You can also copy data from Excel Viewer to another program. However, you cannot edit data, save a workbook, or create a new workbook. This download is a replacement for Excel Viewer 97 and all previous Excel Viewer versions. See http://www.microsoft.com/download/en/details.aspx?DisplayLang=en&id=10 to download the free Microsoft® Excel Viewer. The Google DocsTM program will also open Microsoft® Office.

• One of the format options for the feedback report is Character Separated Values (.csv) files. This is a commonly recognized delimited data format that has fields/columns separated by the comma character or other character and records/rows separated by a line feed or a carriage return and line feed pair. The .csv files generated for the feedback report will use the [tab] as the delimiting character. The .csv file type is generally accepted by spreadsheet programs and database management systems using the application's native features.

• Users may need to turn off their web browser’s Pop-up Blocker or temporarily allow Pop-up files in order to download the feedback report.

• Regardless of the format, users should preview their feedback reports prior to printing. In Microsoft® Excel, view Print Preview to ensure all worksheets show as “fit to one page”.

• If you need assistance with the IACS registration process (i.e., forgot ID, password resets, etc.), contact the QualityNet Help Desk at 1-866-288-8912 (TTY 1-877-715-6222) or [email protected] (Monday-Friday 7:00 a.m.-7:00 p.m. CT). You may also contact them for feedback report assistance, including accessing the Portal.

• Contact your Carrier or A/B MAC with general payment questions. The Provider Contact Center Toll-Free Numbers Directory offers information on how to contact the appropriate provider contact center and is available for download at: http://www.cms.gov/MLNGenInfo/01_Overview.asp.

Copyright, Trademark, and Code-Set Maintenance Information

• CPT® codes are copyright 2011 American Medical Association. G-codes are in the public domain. • HCPCS is maintained by the Centers for Medicare & Medicaid Services (CMS). • Microsoft® Windows operating system, XP Professional, Vista, and Internet Explorer are registered trademarks of the Microsoft Corporation. • Mozilla® Firefox is a registered trademark of Mozilla. • Apple® Safari is a registered trademark of Apple Inc. • Sun® Java runtime environmentTM is a trademark of Sun Microsystems, Inc. or its subsidiaries in the United States and other countries. • Adobe®, the Adobe logo, and Acrobat are registered trademarks or trademarks of Adobe Systems Incorporated in the United States and/or

other countries. • Google Docs™ program is a registered trademark of Google Inc.

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1206.pdf

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1206.pdf


http://www.adobe.com/products/acrobat/readstep2.html?promoid=BUIGO

http://www.microsoft.com/download/en/details.aspx?DisplayLang=en&id=10


http://www.cms.gov/MLNGenInfo/01_Overview.asp


Appendix A: 2014 eRx Payment Adjustment Feedback Report Definitions Table 1: Reporting Detail for the Taxpayer Identification Number (Tax ID or TIN)

Term Definition Tax ID Name Legal business name associated with a TIN. Eligible professional’s name identified

by matching the identifier number in the CMS national Provider Enrollment Chain and Ownership System (PECOS) database. If the organization’s or professional's enrollment record or enrollment changes have not been processed and established in the national PECOS database as well as at the local Carrier or A/B MAC systems at the time this report was produced, this is indicated by "Not Available". This does not affect the organization’s or professional’s enrollment status or subjectivity to the 2014 eRx payment adjustment; only the system's ability to populate this field in the report.

Tax ID Number The masked TIN, whether individual or corporate TIN, Employer Identification Number (EIN), or individual professional’s Social Security Number (SSN).

Report Time Period Data from the Medicare Part B claims received for the dates of service January 1–October 31, 2012 that were processed into NCH by December 31, 2012 (the last Friday in December is the 28th and data will not be processed throughout the weekend). Note: This report includes partial year reporting for the 2012 eRx program year based on claims data only

NPI Number (Individuals only)

National Provider Identifier of the eligible professional billing under the TIN.

NPI Name (Individuals only)

Eligible professional’s name identified by matching the identifier number in the CMS national Provider Enrollment Chain and Ownership System (PECOS) database. If the organization’s or professional's enrollment record or enrollment changes have not been processed and established in the national PECOS database as well as at the local Carrier or A/B MAC systems at the time this report was produced, this is indicated by "Not Available". This does not affect the organization’s or professional’s enrollment status or eligibility for a 2014 eRx payment adjustment; only the system's ability to populate this field in the report.

Reporting Denominator: Applicable Cases That Could Be Reported

The number of 2012 eRx denominator-eligible visits during the preliminary reporting period (January 1–October 31, 2012) for which the NPIs were eligible to report for the measure, if an eRx encounter occurred.

Actual # of eRx G-Codes Reported

The number of eRx G-Code submissions for a measure whether or not the QDC was valid or appropriate. If the Actual # of eRx G-Codes Reported is larger than the Reporting Denominator number, the eligible professional submitted eRx QDCs to events that were not applicable or appropriate.

Reporting Numerator: Valid Unique eRx G-codes Reported

The number of valid eRx G-codes submitted via claims during the preliminary reporting period (January 1–October 31, 2012) for all NPIs.

Currently Subject to the 2014 eRx Payment Adjustment

Yes/No: “Yes” if the TIN/NPI or group practice participating in eRx GPRO TIN may be eligible for the payment adjustment; “No” if the TIN/NPI or eRx GPRO TIN is not eligible for the payment adjustment.

More information regarding payment adjustment calculations can be found on the CMS website, http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ERxIncentive/.




Term Definition Reason Explanation why the individual eligible professional or group practice participating in

eRx GPRO may or may not be subject to the eRx payment adjustment. Individual NPI

Subject to eRx payment adjustment o Did not successfully report at least 25 valid eRx G-codes

Not subject to payment adjustment o Reported Successfully

eRx GPRO Subject to eRx payment adjustment

o Did not successfully report the required amount of valid eRx G-codes

Not subject to eRx payment adjustment o Reported Successfully


Table 2: NPI Reporting Detail (Individuals Only)

Term Definition Tax ID Name Legal business name associated with a TIN. Eligible professional’s name identified

by matching the identifier number in the CMS national Provider Enrollment Chain and Ownership System (PECOS) database. If the organization’s or professional's enrollment record or enrollment changes have not been processed and established in the national PECOS database as well as at the local Carrier or A/B MAC systems at the time this report was produced, this is indicated by "Not Available". This does not affect the organization’s or professional’s enrollment status or subjectivity to the 2014 eRx payment adjustment; only the system's ability to populate this field in the report.

Tax ID Number The masked TIN, whether individual or corporate TIN, Employer Identification Number (EIN), or individual professional’s Social Security Number (SSN).

NPI Number

Individual rendering National Provider Identifier of the eligible professional billing under the TIN.

Report Time Period Data from the Medicare Part B claims received for the dates of service January 1–October 31, 2012 that were processed into NCH by December 31, 2012 (the last Friday in December is the 28th and data will not be processed throughout the weekend). Note: This report includes partial year reporting for the 2012 eRx Program Year based on claims data only

Reporting Denominator: Applicable Cases That Could Be Reported

The number of 2012 eRx denominator-eligible visits during the preliminary reporting period (January 1–October 31, 2012) for which the NPI was eligible to report for the measure, if an eRx encounter occurred.

Actual # of eRx G-Codes Reported

The number of eRx G-Code submissions for a measure whether or not the QDC was valid or appropriate. If the Actual # of eRx G-Codes Reported is larger than the Reporting Denominator number, the eligible professional submitted eRx QDCs to events that were not applicable or appropriate.

Reporting Numerator: Valid Unique eRx G-codes Reported

The number of valid eRx G-codes submitted via claims during the preliminary reporting period (January 1–October 31, 2012) for NPI.

Currently Subject to the 2014 eRx Payment Adjustment

Yes/No: “Yes” if the TIN/NPI may be eligible for the payment adjustment; “No” if the TIN/NPI may not be eligible for the payment adjustment.

More information regarding payment adjustment calculations can be found on the CMS website, http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ERxIncentive/.

Reason Explanation why the individual may or may not be subject to the eRx payment adjustment.

Subject to the payment adjustment o Did not successfully report at least 25 valid eRx G-codes

Not subject to the payment adjustment o Reported Successfully



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